Mammography: A Billion Without Benefit?

Can you spend a billion on breast cancer screenings without benefit? Researchers at Yale School of Medicine believe the answer is yes, but officials at the American College of Radiology (ACR) say the situation is not so simple. In a study also published online by JAMA Internal Medicine, lead researcher Cary P. Gross, MD, concluded that “even though Medicare spends over $1 billion per year on breast cancer screenings such as a mammography, there is no evidence that higher spending benefits older women.” According to a wrap-up in Yale News, the study sought to provide “a comprehensive understanding of breast cancer expenditures that incorporate the cost of screening and associated work-up, as well as treatment.” The JAMA abstract reveals that researchers identified 137,274 women ages 66 to 100 years who had not had breast cancer, and assessed the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. After tallying annual costs to fee-for-service Medicare for breast cancer screening-related procedures (comprising screening plus workup), the totals reached $1.08 billion and $1.36 billion. “For women 75 years or older, annual screening-related expenditures exceeded $410 million,” say researchers in the abstract summary. “Age-standardized screening-related cost per beneficiary varied more than 2-fold across regions (from $42 to $107 per beneficiary); digital screening mammography and CAD accounted for 65% of the difference in screening-related cost between HRRs in the highest and lowest quartiles of cost.” Gross and fellow researchers concluded that “the cost to Medicare of breast cancer screening exceeds $1 billion annually in the fee-for-service program. Regional variation is substantial and driven by the use of newer and more expensive technologies; it is unclear whether higher screening expenditures are achieving better breast cancer outcomes.” “I think what they are saying here is that people have spent all this money on digital technology, and they are not sure there is a benefit,” says Geraldine McGinty, MD, MBA, who also believes these kinds of well publicized studies are ultimately confusing for prospective patients. As one example of the wide media exposure, the Boston Globe boldly proclaimed that “mammography spending boost may not save older women’s lives” in its Jan 14 issue. “Every time this kind of information comes out in the mainstream media, it is going to lead to a few patients who say, ‘Maybe I don’t need a mammogram,’” laments McGinty, who serves as chair of the ACR Commission on Economics. “And that is really unfortunate, because mammography screening works.” As recently as June 2012, a Mayo Clinic analysis reported that that the rate of women in their 40s who received preventive mammographies had fallen by almost 6% nationwide. That drop was largely attributed to the U.S. Preventive Services Task Force (USPSTF) recommendation against routine mammograms for women in this age group. McGinty hopes the latest study will not accelerate this trend. “Again, I worry about the constant drip of spreading doubt,” she says, “because it has already resulted in a reduction of mammography utilization, and that is a bad thing.”